[*Anya*]

Part I

Creating a Safe and Caring Health Care Context for Women Who Have Sex with Women
Posted: 07/12/2012; Journal for Nurse Practitioners. 2012;8(6):464 © 2012 Elsevier Science, Inc.

The purpose of this article is to introduce the concept of cultural safety as it relates to women who have sex with women and offer nurse practitioners who work with this population an integrated literature review regarding relevant research and recommended practices.

Introduction

Women who have sex with women (WSW) are a population that has long been stigmatized and marginalized within our society. Commonly, WSW are referred to as lesbian or bisexual. However, many WSW do not self-identify this way, so using the term WSW is more inclusive. This article will use WSW and lesbian interchangeably and will mention people of other sexual minorities: lesbian, gay, bisexual, and transgender (LGBT) to be compatible with references and citations.

There has been incremental improvement in the United States toward societal acceptance of the LGBT population, yet there is still stigma associated with living anything other than a heterosexual lifestyle.[1,2] Neville and Henrickson[2] posit that consequences of these attitudes lead to violence, homophobia, and heterosexism that affect the mental and physical health of the LGBT population. "Although homosexuality has been removed from the list of diagnoses in the diagnostic manual of the American Psychiatric Association, the relationship between homosexuality and sickness has proved more enduring in the minds of many providers."[1]

It is difficult to accurately estimate the size of the LGBT or WSW populations because of poor research methods, nonstandardization of terms, and the historical invisibility of the population. Different estimates are given in the literature, all of which are relatively low. The Institute of Medicine[3] (IOM) sentinel report on lesbian health from 1999 lists the estimated percentage at 2%–10% of the population. The range of 1%–10% is reflected in other references.[4–8]

Dibble et al[9] said, "Lesbians are a diverse group of women from every ethnic, religious, economic, cultural, and age group." Some agencies have brought attention to the health disparities and consequent need for culturally safe care, including the Joint Commission,[10] Healthy People 2010 and 2020,[11,12] and the IOM.[3]

Many nurse practitioners (NPs) are educated in the specific health and cultural needs of the WSW population and provide exemplary care for this group. However, although many NPs provide culturally safe care for WSW, there are also accounts of discrimination, abuse, assumptions, voyeurism, lack of knowledge, and substandard care toward the WSW population in health care.[4,5,13,14] Some WSW report that, after coming out to their health care provider, they were treated with physical roughness during their exam.[13] Some women have been denied care after their providers found out about their sexual orientation.[5] According to Bjorkman and Malterud,[13] since many health care providers assume that women are heterosexual, a woman who self-identifies as lesbian has to "choose to actively intervene and inform the professional about her lesbian orientation or passively pass as heterosexual." They also point out that the pressure to disclose sexuality is particularly present during gynecologic exams, when the provider doesn't understand when the patient reports being sexually active but not using contraception and having no possibility of being pregnant.[13]

Much of the literature on WSW identifies gaps in providing culturally safe care for this population. Cultural safety is defined as "the effective nursing practice of a person or family from another culture, and is determined by that person or family."[15] The purpose of this article is to introduce the concept of cultural safety as it relates to WSW and offer NPs who work with this population an integrated literature review regarding relevant research and recommended practice.

Literature Review

The literature review is organized by common health issues found among WSW. The issues discussed are obesity and cardiovascular disease (CVD), cancer and screening, mental health and substance abuse, and sexually transmitted diseases (STDs) and reproductive health.

Obesity and Risk for Cardiovascular Disease

Many sources suggest that WSW may tend to have higher rates of obesity than heterosexual women.[6,9,16] "Lesbians are more likely than heterosexual women to have high body mass index, waist circumference, and waist-to-hip ratio; however, they are also more likely to engage in regular exercise."[6] Boehmer and Bowen[17] also found more obesity in women of sexual minority compared to women with a male partner.

There is conflicting information on the risk of CVD for the WSW population. Roberts[16] said, "Research has found increased risk for CVD in lesbians." On the other hand, Mravcak[6] said, "There is no proven increase in the risk of CVD among lesbians and bisexual women." Risk factors for CVD in the WSW population provided by Roberts include "higher rates of obesity, smoking, alcohol use, and less intake of fruits and vegetables."[16]

Cancer and Screening

Cervical Cancer and Dysplasia. Hutchinson et al[4] said, "All women, regardless of sexual preference, are at risk for cervical cancer." Many providers are under the assumption that WSW do not need regular Papanicolaou (Pap) smears because of perceived low risk of cervical dysplasia and cancer.[6,7] This belief may also be held by many WSW themselves.[16] However, human papillomavirus (HPV), the believed cause for 90% of cervical dysplasia, can be transmitted between women.[5] Cervical neoplasia has been found in WSW with no reported history of male partners.[18] In addition, most WSW do report a history of male sexual partners.[4-7]

There has been evidence that WSW have lower rates of cervical cancer screening than do heterosexual comparison groups.[16] One study of 7,000 lesbians cited by Hutchinson et al[4] reported, "Lesbians had higher rates of abnormal Pap results than rates reported in the general US population." Clearly, best practices suggest that WSW should not be excluded from regular cervical cancer screening. Moreover, NPs may need to educate WSW that they need this screening.

Breast Cancer. Several reasons are identified in the literature why WSW may be at a higher risk to develop breast cancer than heterosexual women. It is believed that WSW do not seek preventive mammograms as often as heterosexual women, citing reasons of mistrust of health care providers, negative past experiences, and perceived homophobia in the health care setting.[4] However, the data suggesting that WSW do not receive screening mammography as much as heterosexual women is not consistent. Mravcak[6] said, "Rates of mammogram screening in lesbians and bisexual women are similar to those in heterosexual women." Also discussed in the literature are lower rates of breast self-exam (BSE) among the lesbian population.[5]

It is commonly believed that many WSW are at a higher risk for developing some cancers as a result of higher rates of nulliparity, smoking, alcohol use, and obesity.[4,16] O'Hanlan et al[7] identify these risks and the use of menopausal hormone replacement therapy as a risk. This information is not well researched and needs further study. As Spinks et al[5] pointed out, "Current research has not accurately identified the incidence of breast cancer in lesbians; however, simply being female places lesbian clients at risk." NPs need to encourage WSW to perform monthly BSE, have regular cancer screening visits with a health care provider, and screening mammograms by following the guidelines for best practices as suggested for all women.

Ovarian Cancer. There is little research available about the occurrence of ovarian cancer in WSW compared to the general population of women. Dibble et al[9] performed a study on risk factors for ovarian cancer for lesbians and heterosexual women. This study of over 1,000 women found, "As expected from previous reports, the lesbians had significantly fewer pregnancies, miscarriages, and abortions and lower use of birth control pills. These variables place lesbians at a higher risk for developing ovarian cancer."[9] "Whether women are at increased risk for ovarian cancer secondary to exposure to HRT [hormone replacement therapy] is not clear. The prevalence of HRT usage among lesbians is unknown."[9] In addition, the authors suggest it would be helpful to include sexual orientation in tumor registry data.[9]

Mental Health

Mravcak[6] said, "Most lesbians and bisexual women are emotionally healthy and well-adjusted." However, mental illness, especially depression, occurs in the WSW population. Depression is the most common mental illness reported in WSW[16] and has shown in some studies to occur in higher rates in WSW than in heterosexual women.[19]